Permanent sterilisation - a French taboo?

Past trauma, male-dominated society or a pro-birth political tradition... "Sterilisation for contraceptive purposes" remains extremely marginalised in France, despite a law passed on 4th July 2001 which made the practice official in France for the first time. Ten years on, where do we stand?

"Are you sure? Don’t you want to keep your options open, in case you want a boy?" Suzanne, already mother to four girls, would have preferred not to hear these malicious questions, with an air of chauvinism, coming from the mouth of her gynaecologist. Least of all when she had just confided in him her wish to turn to permanent contraception in order not to have any more children. Ever. Neither girl, nor boy, nor anything. The problem is that the number of women who find themselves in the same situation as Suzanne is in the hundreds, and the situation is even more tricky if they are less than 40 years old, or don’t have any children.

"There are very few doctors who suggest permanent contraception, especially when they are dealing with young people; even after an abortion, despite the obvious failure of their method of contraception" explains Carine Favier. According to the president of the National movement for Family Planning, some people are ignorant even of the existence of the 2001 law. "So nothing happens until the request comes from the women" she sighs. "But as most of the time they haven’t heard of it either, the question doesn’t arise until they have undesired side-effects from their temporary methods of contraception. It’s not just because they no longer want children."

However, even when the women are well informed, making this request is still difficult in a society where motherhood remains sacrosanct. Carole, married for eight years, bears witness to this. "My husband already had two children when we met. He wasn’t against us having children together, but since I wasn’t convinced, he never pressured me either. When I reached 40 years old, I realised that I was sure I didn’t want to be a mother." Fearing the side effects of taking the Pill long term, Carole decided to tell her gynaecologist about her situation; without yet daring to bring up permanent contraception, which a colleague had recommended to her. "She only suggested that I replaced the Pill with the patch; another hormone diffuser, and what’s more it’s not particularly recommended for the over-forties. As a result, I had to carry out my own research to be able to go to a specialist. With hindsight, I’m annoyed with my gynaecologist for not sending me down this route."

It’s not without reason that French doctors don’t venture much into the topic of voluntary sterilisation, but indeed because this practice is still perceived as an amputation, rather than a lifestyle choice. It must be said that its image suffers from a dark past. Practised since the latter part of the 19th century, tying of tubes and vasectomy have actually long been carried out to eugenic ends, particularly in Sweden where it continued until the 1970s, or in India in the context of "enforced family planning". For Nathalie Bajos, a sociologist specialising in demographics at the National Institute for Health and Medical Research (Inserm), this context still only partly explains the hesitation of French women, for which they are now paying the price. "The country has been marked by a tradition of very pro-birth politics, so the connection with the birth rate and fertility has always been very valued; so much so that before 2001 the vagueness of the law remained complete on this subject. You only have to see just how much the government crows about having the best birthrate in Europe to understand why the lack of social recognition with regard to childless women remains extremely strong."

For Nathalie Bajos, these social portrayals inevitably influence the behaviour of doctors, who in turn "play a key role with regards to the population". Profiting from women who are often powerless in the face of knowledge and medical power, some doctors don’t hesitate in deliberately putting the brakes on resorting to these methods, particularly since the arrival of the micro-implant method in 2002, which considerably simplifies the process. Without requiring any anaesthetic at all, the insertion of these flexible implants into the Fallopian tubes is completed in less than ten minutes and via the vagina. No hormones, no incisions, no cauterisation.

"The procedure is no more painful than a well-carried-out IUD insertion, and over the following three months the body forms a natural barrier around the implants, permanently preventing the sperm from reaching the ovum" explains Sergine Heckel.

This gynaecologist and obstetrician regularly performs the different sterilisation procedures in a Lyons hospital. In her opinion, tube-tying is not only less reliable, since the failure rate sits at 1.8% against 0% for micro-implants, but also carries risks of perforation of the digestive wall, and even death. It’s not surprising then, that out of the 70,000 female sterilisations carried out since its introduction in 2002, this new method of micro-implants has already attracted 50% of those women. Until very recently, the reimbursement for micro-implants; much less expensive than tube-tying, was automatic as long as the procedure was carried out in the public sector. But, in 2010, health insurance companies began to back-pedal and brought in restrictions by means of a decree. "Obviously, Social Security doesn’t want to make this procedure too easy to choose, hence their decision to announce cutbacks in the reimbursement for micro-implant procedures for women aged under forty. Broadly speaking, it really should be earned" deplores Carine Favier. In the eyes of the president of the Family Planning movement, the introduction of this criteria represents nothing less than the resurgence of an archaic male dominance, which continues to prevail over the wishes of women. "They are still thought of as vulnerable, and not able to make their decisions alone. Whether it’s in a rural setting or in a city, it’s the same: they are systematically faced with the argument that they will regret it in the future; something which is actually extremely rare, and that’s when they aren’t asked for written authorisation from their partner!"

Faced with this discrimination, happily Carine Favier’s voice is not alone. Joining with the militants of the Family Planning movement and with feminist associations, for some months gynaecologist organisations have been on the defensive to present a petition to the central government, asking for the cancellation of this reimbursement cutback policy. While waiting for a reaction which is not forthcoming, the gynaecologist Sergine Heckel holds to her methods. Getting around the rules as best she can, she continues to get the operations she performs on young women reimbursed.
"It’s specified that there must be contraindications to pregnancy. Indeed, between the ages of thirty-five and forty, many women have significant problems with contraception, and this failure often leads to unwanted pregnancies. And although always forgotten, abortions also carry not inconsiderable risks, particularly if a general anaesthetic is needed. Therefore I systematically put down a contraindication to pregnancy, but of a psychological nature."

According to the sociologist Nathalie Bajos, it is high time that the French decision-makers shouldered the responsibility, because their attitude towards contraception is not only dangerous, but completely absurd in view of future issues.

"The age at which women enter motherhood is increasingly delayed, late pregnancies are constantly rising, and step-families and the second lives of couples play a sizeable role in these phenomena. It’s estimated that the average length of the sexually reproductive period is thirty-five years. Out of the thousands of sexual encounters that this represents, only two or three will actually be fertile, so the diversification of the range of contraceptive methods is a matter of urgency, in order to respond in the most appropriate manner to these new trends" she pleads.

For the time being, vasectomy, which has always been wrongly associated with a loss of virility, is only performed on average on 1,500 French men each year. As for the so-called "range" of female contraceptives, it’s often restricted to the Pill for the first half of the reproductive life, and then to the coil for the second half. "And once again, the refusal to offer the IUD to women with less than two children or who are less than thirty-five years old is still very common" continues the researcher. “Even when the women can’t stand the Pill, they are dissuaded by talk of the infection risks that sterilisation can carry." Curiously, while the unquenchable pro-life camp is continuing to expand, rallied by the venomous editors following the style of Zemmour, capable of talking about the right to abortion as a "mini-baby-boom" failed because of "the economic growth and the political strength of France", the subject doesn’t even seem to occur to the Ministry of Health. Far from shifting gear in favour of a more adequate contraceptive policy, the majority of decision-makers prefer to feign indignation each year at a "too high" level of abortions. Of course, without forgetting to methodically suffocate the centres that carry them out.

The contraceptive failure

According to a report by IGAS (the Inspectorate General for Social Affairs), the French contraception system, which gives preference to medical methods, experiences a significant failure rate; often leading to abortions. One in three pregnancies are unplanned, and in 60% of cases these are aborted.
Two out of every three unplanned pregnancies occur in women who were taking contraceptives (the Pill or coil in 42% of cases). 14% of abortions involve women aged between 35 and 39. However, problems with observance or errors of usage can be avoided with better information and a contraceptive based more on the individual’s needs.